{ "source_file": "CRH 23075530.pdf", "document_type": "crh", "sejour": { "sexe": "F", "age": 51, "date_entree": "17/04/2023", "date_sortie": "21/04/2023", "duree_sejour": 4 }, "diagnostic_principal": { "texte": "Tabagisme", "cim10_suggestion": "F17.2", "cim10_confidence": "high", "cim10_final": "F17.2", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "nuke3", "source_page": 1, "source_excerpt": "...nd@ch-cotebasque.fr\nAllergie : Métronidazole, œufs\nDr Mathieu AUZI\nDES Médecine Générale\nToxiques : Tabagisme actif estimé à 4PA.\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr Traitements à l'entrée..." }, "dp_selection": { "chosen_index": 2, "chosen_term": "Tabagisme", "chosen_code": "F17.2", "verdict": "CONFIRMED", "evidence": [ "Score 5.0 — source: regex (section forte)", "Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»", "Delta +3.0 vs Diabète de type 2 (E11.9)" ], "reason": "Écart score 3.0 >= seuil 3.0", "candidates": [ { "index": 2, "term": "Tabagisme", "code": "F17.2", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 5.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2 } }, { "index": 1, "term": "Diabète de type 2", "code": "E11.9", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 2.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2, "comorbidity_malus": -3 } }, { "index": 3, "term": "Hypothyroïdie", "code": "E03.9", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 5, "term": "Infection urinaire", "code": "N39.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 6, "term": "Thrombocytose", "code": "D47.3", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 0, "term": "Hypertension artérielle", "code": "I10", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 0.0, "score_details": { "section": 3, "confidence": 0, "comorbidity_malus": -3 } }, { "index": 4, "term": "Trouble dépressif caractérisé", "code": "F32.9", "source": "llm_das", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": -2.0, "score_details": { "section": 1, "confidence": 0, "comorbidity_malus": -3 } } ], "debug_scores": { "top1": 5.0, "top2": 2.0, "delta": 3.0 } }, "dp_crh_only": { "chosen_index": 2, "chosen_term": "Tabagisme", "chosen_code": "F17.2", "verdict": "CONFIRMED", "evidence": [ "Score 5.0 — source: regex (section forte)", "Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»", "Delta +3.0 vs Diabète de type 2 (E11.9)" ], "reason": "Écart score 3.0 >= seuil 3.0", "candidates": [ { "index": 2, "term": "Tabagisme", "code": "F17.2", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 5.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2 } }, { "index": 1, "term": "Diabète de type 2", "code": "E11.9", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 2.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2, "comorbidity_malus": -3 } }, { "index": 3, "term": "Hypothyroïdie", "code": "E03.9", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 5, "term": "Infection urinaire", "code": "N39.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 6, "term": "Thrombocytose", "code": "D47.3", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 0, "term": "Hypertension artérielle", "code": "I10", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 0.0, "score_details": { "section": 3, "confidence": 0, "comorbidity_malus": -3 } }, { "index": 4, "term": "Trouble dépressif caractérisé", "code": "F32.9", "source": "llm_das", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": -2.0, "score_details": { "section": 1, "confidence": 0, "comorbidity_malus": -3 } } ], "debug_scores": { "top1": 5.0, "top2": 2.0, "delta": 3.0 } }, "dp_final": { "chosen_index": 2, "chosen_term": "Tabagisme", "chosen_code": "F17.2", "verdict": "CONFIRMED", "evidence": [ "Score 5.0 — source: regex (section forte)", "Conclusion: «diabète de type 2 bien équilibré pendant l'hospitalisation, pas de modification de traitement\nmgschwind@ch-cotebasque.fr urticaire chronique\nDr Mathieu AUZI\nDES Médecine Générale\nDIU Nutrition\nRPPS : 10100422012\nmauzi@ch-cotebasque.fr\nDr Am»", "Delta +3.0 vs Diabète de type 2 (E11.9)" ], "reason": "Écart score 3.0 >= seuil 3.0", "candidates": [ { "index": 2, "term": "Tabagisme", "code": "F17.2", "source": "regex", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 5.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2 } }, { "index": 1, "term": "Diabète de type 2", "code": "E11.9", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 2.0, "score_details": { "section": 3, "confidence": 0, "diag_section_bonus": 2, "comorbidity_malus": -3 } }, { "index": 3, "term": "Hypothyroïdie", "code": "E03.9", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 5, "term": "Infection urinaire", "code": "N39.0", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 6, "term": "Thrombocytose", "code": "D47.3", "source": "llm_das", "is_comorbidity_like": false, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": 1.0, "score_details": { "section": 1, "confidence": 0 } }, { "index": 0, "term": "Hypertension artérielle", "code": "I10", "source": "regex", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 3, "num_occurrences": 1, "score": 0.0, "score_details": { "section": 3, "confidence": 0, "comorbidity_malus": -3 } }, { "index": 4, "term": "Trouble dépressif caractérisé", "code": "F32.9", "source": "llm_das", "is_comorbidity_like": true, "is_symptom_like": false, "is_act_only": false, "section_strength": 1, "num_occurrences": 1, "score": -2.0, "score_details": { "section": 1, "confidence": 0, "comorbidity_malus": -3 } } ], "debug_scores": { "top1": 5.0, "top2": 2.0, "delta": 3.0 } }, "quality_flags": { "rag_status": "error", "crh_only_mode": true }, "diagnostics_associes": [ { "texte": "Hypertension artérielle", "cim10_suggestion": "I10", "cim10_confidence": "high", "cim10_final": "I10", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "regex" }, { "texte": "Diabète de type 2", "cim10_suggestion": "E11.9", "cim10_confidence": "high", "cim10_final": "E11.9", "sources_rag": [], "preuves_cliniques": [], "est_cma": true, "niveau_severite": "non_evalue", "niveau_cma": 2, "source": "regex", "source_page": 1, "source_excerpt": "...DESC Nutrition\nAncien Chef de Clinique CHU Personnels :\nTours - Hypopthyroïdie\nRPPS : 10002083912\n- Diabète de type 2 connu depuis 6 ans\nlritz@ch-cotebasque.fr\n- Infections urinaires\nDr Elisa MAURY - HTA\nDES Endocrino..." }, { "texte": "Hypothyroïdie", "cim10_suggestion": "E03.9", "cim10_confidence": "high", "cim10_final": "E03.9", "justification": "Antécédent actif mentionné dans les ATCD avec traitement par lévothyroxine 50mg à l'entrée. Pathologie chronique pertinente pour le séjour d'un patient diabétique déséquilibré, mobilisant des ressources de suivi.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das" }, { "texte": "Trouble dépressif caractérisé", "cim10_suggestion": "F32.9", "cim10_confidence": "medium", "cim10_final": "F32.9", "justification": "Episodes dépressifs caractérisés avec hospitalisations psychiatriques antérieures mentionnés explicitement. Traitement par vortioxétine 10mg à l'entrée. Pertinent car contribue aux difficultés de prise en charge à domicile (thymie basse) et mobilise des ressources de suivi psychologique.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das" }, { "texte": "Infection urinaire", "cim10_suggestion": "N39.0", "cim10_confidence": "low", "cim10_final": "N39.0", "justification": "Antécédent d'infections urinaires récurrentes mentionné dans les ATCD. Contexte clinique indique 'Complications : Infection' sans autre précision. Pertinent pour un patient diabétique avec antécédent d'infections urinaires.", "sources_rag": [], "preuves_cliniques": [], "est_cma": true, "niveau_severite": "non_evalue", "niveau_cma": 2, "source": "llm_das" }, { "texte": "Thrombocytose", "cim10_suggestion": "D47.3", "cim10_confidence": "low", "cim10_final": "D47.3", "justification": "Plaquettes 424 [N: 150-400] (↑) - valeur élevée. Peut être réactionnelle à l'infection mentionnée, mais représente une anomalie biologique significative mobilisant des ressources.", "sources_rag": [], "preuves_cliniques": [], "niveau_severite": "non_evalue", "niveau_cma": 1, "source": "llm_das" } ], "actes_ccam": [], "antecedents": [], "traitements_sortie": [], "biologie_cle": [ { "test": "ASAT", "valeur": "29", "valeur_num": 29.0, "anomalie": false, "quality": "ok", "source_page": 2, "source_excerpt": "...inologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µ..." }, { "test": "ALAT", "valeur": "29", "valeur_num": 29.0, "anomalie": false, "quality": "ok", "source_page": 2, "source_excerpt": "...Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 1..." }, { "test": "GGT", "valeur": "107", "valeur_num": 107.0, "anomalie": true, "quality": "ok", "source_page": 2, "source_excerpt": "...g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAn..." }, { "test": "PAL", "valeur": "96", "valeur_num": 96.0, "anomalie": false, "quality": "ok", "source_page": 2, "source_excerpt": "...es 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAngers HBA1c 1..." }, { "test": "Potassium", "valeur": "4.5", "valeur_num": 4.5, "anomalie": false, "quality": "ok" }, { "test": "Hémoglobine", "valeur": "14.2", "valeur_num": 14.2, "anomalie": false, "quality": "ok" }, { "test": "Plaquettes", "valeur": "424", "valeur_num": 424.0, "anomalie": true, "quality": "ok", "source_page": 2, "source_excerpt": "...Biologie d'entrée :\nDES Endocrinologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Cl..." }, { "test": "Leucocytes", "valeur": "14.57", "valeur_num": 14.57, "anomalie": true, "quality": "ok", "source_page": 2, "source_excerpt": "...:\nDr Delphine DEMARSY Biologie d'entrée :\nDES Endocrinologie et Mal. Hb 14.2g/dL, Hématies 5.08t/L, Leucocytes 14.57G/L, Plaquettes 424G/L\nMétaboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrit..." }, { "test": "Créatinine", "valeur": "50", "valeur_num": 50.0, "anomalie": false, "quality": "ok", "source_page": 2, "source_excerpt": "...aboliques\nASAT 29U/L, ALAT 29U/L, GGT 107U/L, PAL 96U/L.\nDESC Nutrition\nAncien Chef de Clinique CHU Créatinine 50µmol/L, DFG 108mL/min\nAngers HBA1c 11.2%, K+ 4.5mmol/L\nRPPS : 10004401718 LDL 1.24g/L, HDL 0.42g/..." } ], "biologie_discarded": [], "imagerie": [], "complications": [ { "texte": "Infection", "source_page": 1, "source_excerpt": "...- Hypopthyroïdie\nRPPS : 10002083912\n- Diabète de type 2 connu depuis 6 ans\nlritz@ch-cotebasque.fr\n- Infections urinaires\nDr Elisa MAURY - HTA\nDES Endocrinologie et Mal.\n- Notion de problème hépatique\nMétaboliq..." } ], "alertes_codage": [ "QUALITE DEGRADEE : erreur RAG — codage sans référentiels", "2 CMA probables détectées — impact potentiel sur le niveau de sévérité GHM", "CMA niveau 2 : 'Diabète de type 2' (E11.9) — sévérité non_evalue", "CMA niveau 2 : 'Infection urinaire' (N39.0) — sévérité non_evalue", "QC: DAS I10 (Hypertension artérielle) à reconsidérer — Aucune preuve clinique. Pas de mention de l'HTA dans les données fournies. Absence de traitement antihypertenseur documenté. Codage injustifié.", "QC: DAS E11.9 (Diabète de type 2) à reconsidérer — Aucune preuve clinique. Pas de glycémie anormale, pas de mention du diabète dans les ATCD ou le traitement. Codage sans fondement.", "QC: ⚠️ ALERTE CRITIQUE : 4 codes sur 7 sont codés SANS PREUVE DOCUMENTÉE dans le dossier (F17.2, I10, E11.9, N39.0). Cela constitue une violation majeure des règles PMSI.", "QC: ⚠️ ALERTE : La complication 'Infection' est codée de manière spéculative en N39.0 (ITU) sans confirmation clinique. Demander la documentation précise du type et du site d'infection.", "QC: ⚠️ ALERTE : D47.3 (thrombocytose essentielle) est un diagnostic hématologique grave, inapproprié pour une thrombocytose réactionnelle. À supprimer.", "QC: ⚠️ ALERTE : F32.9 nécessite clarification : trouble dépressif actuel ou antécédent ? Distinction importante pour le codage.", "QC: 📋 RECOMMANDATION : Demander au clinicien de compléter/clarifier le dossier avant validation finale. Codage actuel non conforme aux standards PMSI (absence de justification documentée).", "VETOS[PDF]: NEED_INFO (score=25)", "VETO-02 [MEDIUM] diagnostics_associes[0]: DAS I10 sans preuve exploitable", "VETO-02 [MEDIUM] diagnostics_associes[2]: DAS E03.9 sans preuve exploitable", "VETO-02 [MEDIUM] diagnostics_associes[3]: DAS F32.9 sans preuve exploitable", "VETO-02 [MEDIUM] diagnostics_associes[4]: DAS N39.0 sans preuve exploitable", "VETO-02 [MEDIUM] diagnostics_associes[5]: DAS D47.3 sans preuve exploitable" ], "source_files": [], "ghm_estimation": { "cmd": "20", "cmd_libelle": "Troubles mentaux liés à l'alcool et aux toxiques", "type_ghm": "M", "severite": 2, "ghm_approx": "20M??2", "cma_count": 2, "cms_count": 0, "alertes": [] }, "controles_cpam": [], "veto_report": { "verdict": "NEED_INFO", "score_contestabilite": 25, "issues": [ { "veto": "VETO-02", "severity": "MEDIUM", "where": "diagnostics_associes[0]", "message": "DAS I10 sans preuve exploitable", "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)" }, { "veto": "VETO-02", "severity": "MEDIUM", "where": "diagnostics_associes[2]", "message": "DAS E03.9 sans preuve exploitable", "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)" }, { "veto": "VETO-02", "severity": "MEDIUM", "where": "diagnostics_associes[3]", "message": "DAS F32.9 sans preuve exploitable", "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)" }, { "veto": "VETO-02", "severity": "MEDIUM", "where": "diagnostics_associes[4]", "message": "DAS N39.0 sans preuve exploitable", "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)" }, { "veto": "VETO-02", "severity": "MEDIUM", "where": "diagnostics_associes[5]", "message": "DAS D47.3 sans preuve exploitable", "citation": "Principe de preuve : tout diagnostic/acte doit être étayé par une trace dans le dossier médical (Guide Méthodologique MCO)" } ] }, "completude": { "checks": [ { "code": "E11.9", "libelle": "Diabète de type 2", "type_diag": "DAS", "items": [ { "categorie": "biologie", "element": "HbA1c", "statut": "present", "valeur": "14.2", "importance": "recommande", "impact_cpam": "HbA1c attendue pour documenter l'équilibre glycémique" }, { "categorie": "biologie", "element": "Glycémie", "statut": "absent", "importance": "recommande", "impact_cpam": "Glycémie de base pour confirmer le diagnostic" } ], "score": 85, "verdict": "defendable", "resume": "1/2 recommandés" }, { "code": "N39.0", "libelle": "Infection urinaire", "type_diag": "DAS", "items": [ { "categorie": "biologie", "element": "ECBU", "statut": "absent", "importance": "obligatoire", "impact_cpam": "ECBU obligatoire pour documenter une infection urinaire" } ], "score": 30, "verdict": "indefendable", "resume": "0/1 obligatoires" } ], "score_global": 57, "verdict_global": "indefendable", "documents_presents": [ "crh" ], "documents_manquants": [] }, "processing_time_s": 20.65, "metrics": { "das_total": 6, "das_active": 6, "das_excluded": 0, "das_removed": 0, "das_ruled_out": 0, "das_no_code": 0, "actes_total": 0, "actes_with_code": 0, "dp_has_code": true }, "rules_runtime": { "router_version": 1, "mode": "strict", "enabled_packs": [ "decisions_core", "vetos_core" ], "always_on_rules": [], "triggers_fired": [] } }